Basic Information
| Provider Information | |||||||||
| NPI: | 1598061335 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMPOS | ||||||||
| FirstName: | CARLOS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | LCSW, LADAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 385 CALLE DE ALEGRA STE A | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880053423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755261105 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 100 W GRIGGS AVE | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880011234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5756472800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2011 | ||||||||
| LastUpdateDate: | 02/24/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 0129141 | NM | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 104100000X | X-07222 | NM | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | C-08875 | NM | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.